Brain insulin circuit. From the basics to impact on the clinic.

The discovery and synthesis of insulin has been vital in the study and treatment of diabetes mellitus. From the studies carried by Dr. Nicolae C. Paulescu in 1921 and descriptions of the pancrein, before those published by Banting and Macleod, the Nobel Prize winners in 1923, more metabolic and non-metabolic actions have been discovered and that are fundamental for life, growth and development of different organs and systems. Diverse studies in animal models have shown the participation in the development of the central nervous system, regeneration, neuronal apoptosis, and synaptic transmission, as well as the effects of its dysregulation in the pathophysiology of diseases such as dementia. Different researchers have demonstrated the synthesis of insulin at the brain, the mechanisms through which the blood-brain barrier crosses and how it regulates non-metabolic systems linked with the nueromodulation. This document to integrate these findings in the cerebral insulin circuit and the translation in clinical practice.

El descubrimiento y la síntesis de la insulina ha sido vitales en el estudio y el tratamiento de la diabetes mellitus. Desde los estudios realizados por el Dr. Nicolae C. Paulescu en 1921 y sus descripciones de la pancreína, antes de los publicados por Banting y Macleod, galardonados con el Premio Nobel en 1923, se han descubierto cada vez más acciones metabólicas y no metabólicas fundamentales para la vida, el crecimiento y el desarrollo de diferentes órganos y sistemas. En la actualidad, el estudio de esta hormona se nutre con más evidencia científica de su utilidad en blancos terapéuticos no metabólicos. Diversos estudios en modelos animales han demostrado su participación en el desarrollo del sistema nervioso central, la regeneración, la apoptosis neuronal y la transmisión sináptica, así como los efectos de su disregulación en la fisiopatología de enfermedades como la demencia. En la actualidad, diferentes investigadores han demostrado la síntesis de insulina en el cerebro, los mecanismos por los cuales atraviesa la barrera hematoencefálica y cómo regula sistemas no metabólicos ligados con la nueromodulación. Este documento trata de integrar estos hallazgos en un sistema insulinérgico cerebral y su posible traducción en la práctica clínica.

[Evacuation of critical care areas due to an initial outbreak of fire in a second level hospital]. / Evacuación de áreas críticas por conato de incendio en un hospital de segundo nivel.

In this letter to the editor, it is exposed an initial outbreak of fire that affected a secondary care center in Córdova, Veracruz, Mexico, and, most of all, the lack of a hospital fire evacuation plan in the presence of a fire event.

En la presente carta al editor, se expone un conato de incendio ocurrido en un hospital de segundo nivel de atención en Córdova, Veracruz, México, y, sobre todo, la carencia de un plan hospitalario de evacuación ante un evento de este tipo.

Metabolic Syndrome and Cardiovascular Disease: A Health Challenge.

Metabolic Syndrome (MetS) is a cluster of risk factors that, taken alone or synergically, are independent predictors of type 2 diabetes and cardiovascular disease (CVD), which are both major public health problems that requires urgent containment actions. Current controversies regarding MetS are focused on ascertain the unifying explanation of molecular and pathophysiological mechanisms originating the syndrome, involving insulin resistance and low-grade chronic inflammation. This review aims to present the clinical relevance of MetS and its complications, as well as the hypotheses addressing its etiopathogenic relation with CVD. We conclude that health policies should emphasize basic research promotion, timely detection and early treatment of MetS, which will help to reduce the risk of CVD and their impact on public health and health-care related costs.

[Hospitales del Instituto Mexicano del Seguro Social durante los sismos de septiembre de 2017. Análisis desde la perspectiva del Programa Hospital Seguro].

INTRODUCTION: The function of hospitals during major emergency or disaster is vital. Their response capacity depends on their geographic location, adequate organization, structural safety and safety of non-structural elements. After September 2017 earthquakes, self-assessment and Safe Hospital Program assessment results were compared in disabled hospitals belonging to the Mexican Institute of Social Security. OBJECTIVE: To compare the Hospital Safety Index (HIS) with self-assessments carried out by the units. METHOD: HIS and the Pan-American Health Organization/World Health Organization checklist were used. The comparison was carried out in 3 hospitals that were disabled after September 2017 earthquakes. RESULTS: Variability was observed in HIS, which revealed self-assessment biases: no hospital obtained a HIS score lower than 0.35, although all 3 were disabled in the immediate phase after the seismic events. CONCLUSIONS: Result variability depends on who applies the instrument. Quick HIS assessment provides an immediate idea of the probability for a hospital to continue functioning in case of disaster and allows determining mitigation actions to increase health facilities' resilience and safety.

INTRODUCCIÓN: La función de los hospitales durante una emergencia mayor o desastre es vital. Su capacidad de respuesta depende de su ubicación geográfica, adecuada organización, seguridad estructural y seguridad de elementos no estructurales. Después de los sismos de septiembre de 2017 se compararon los resultados de las autoevaluaciones y la evaluación del Programa Hospital Seguro en los hospitales inhabilitados pertenecientes al Instituto Mexicano del Seguro Social. OBJETIVO: Comparar el Índice de Seguridad Hospitalaria (ISH) contra las autoevaluaciones realizadas por las unidades. MÉTODO: Se utilizó el ISH y la Lista de Verificación de la Organización Panamericana de la Salud/Organización Mundial de la Salud. La comparación se realizó en tres hospitales inhabilitados posterior a los sismos de septiembre de 2017. RESULTADOS: Se observó variabilidad en los ISH, lo que evidenció sesgos en la autoevaluación: ningún hospital obtuvo una calificación inferior a 0.35 en su ISH aunque tres quedaron inhabilitados en la fase inmediata posterior a los eventos sísmicos. CONCLUSIONES: La variabilidad en los resultados depende de quien aplica el instrumento. La evaluación rápida con ISH proporciona una idea inmediata de la probabilidad de que un hospital continúe funcionando en caso de desastre y permite determinar las acciones de mitigación para incrementar la resiliencia y seguridad de las instalaciones de salud.

Síndrome de insuficiencia respiratoria aguda, 50 años después / Acute respiratory distress syndrome. 50 years later / Síndrome da angústia respiratória aguda 50 anos depois

Resumen: La condición clínica llamada síndrome de insuficiencia respiratoria aguda es una entidad que se conoce desde antes de la Segunda Guerra Mundial; no obstante, no fue hasta el año de 1967 cuando el grupo del Dr. Ashbaugh describió una serie de 12 pacientes con las características clínicas e histológicas particulares a las que llamaron síndrome de dificultad respiratoria aguda. No sólo se describió por primera vez esta entidad clínica, sino que además el grupo del Dr. Ashbaugh hizo mención a la posibilidad del uso de esteroides y ventilación mecánica como probables pilares del tratamiento. Desde entonces y hasta la fecha los criterios diagnósticos, el tratamiento farmacológico, así como las técnicas de soporte mecánico ventilatorio han cambiado, pese a ello esta entidad clínica sigue siendo un reto terapéutico, ya que puede llegar a tener un alto índice de mortalidad, cerca de 40%. La finalidad de este texto es hacer un resumen de las aportaciones más significativas relacionadas con esta entidad en el marco de los 50 años de su descripción.

Abstract: The clinical condition known as acute respiratory distress syndrome, is an entity that has been known since before the Second World War, however it was not until 1967 that the group of Ashbaugh, described a series of 12 patients with clinical and histological special features that called acute respiratory distress syndrome. Not only first he described this clinical entity, if not also the group of Ashbaugh is mention of the possibility of steroid use and mechanical ventilation, as probable gol of treatment. Diagnostic criteria, drug treatment and techniques mechanical support ventilatory have changed, despite which, this clinical entity remains a therapeutic challenge because they can have a high rate of mortality, almost 40%. The purpose of this paper is to summarize the most significant contributions related to this entity, within 50 years of its description.

Resumo: A condição clínica conhecida como síndrome da angústia respiratória aguda (SARA), é uma entidade que temos conhecimento desde antes da Segunda Guerra Mundial, no entanto, não foi até 1967 que o grupo do Dr. Ashbaugh descreveu uma série de 12 pacientes com características clínicas e histológicas especiais que denominou Síndrome da Angústia Respiratória Aguda. Não só se descreveu esta entidade clínica, se não também o grupo do Dr. Ashbaugh fez menção à possibilidade da utilização de esteróides e ventilação mecânica como pilares prováveis ​​do tratamento. Desde então e até os dias de hoje, os critérios de diagnóstico e tratamento medicamentoso, assim como as técnicas de suporte mecânico ventilatório mudaram, apesar de que, esta entidade clínica continua sendo um desafio terapêutico já que pode ter uma alta taxa de mortalidade, quase 40%. O objetivo deste artigo é resumir as contribuições mais significativas relacionadas com esta entidade após 50 anos da sua descrição.

[Emergency and disaster response in critical care unit in the Mexican Social Security Institute: triage and evacuation]. / Atención en emergencias y desastres en las unidades de terapia intensiva del Instituto Mexicano del Seguro Social: triage y evacuación.

Providing medical assistance in emergencies and disaster in advance makes the need to maintain Medical Units functional despite the disturbing phenomenon that confronts the community, but conflict occurs when the Medical Unit needs support and needs to be evacuated, especially when the evacuation of patients in a Critical Care Unit is required. In world literature there is little on this topic, and what is there usually focuses on the conversion of areas and increased ability to care for mass casualties, but not about how to evacuate if necessary, and when a wrong decision can have fatal consequences. That is why the Mexican Social Security Institute gave the task of examining these problems to a working group composed of specialists of the Institute. The purpose was to evaluate and establish a method for performing a protocol in the removal of patients and considering always to safeguard both staff and patients and maintain the quality of care.

La atención en emergencias y desastres implica mantener las unidades médicas en funcionamiento, pese al fenómeno perturbador al que se enfrente la comunidad; sin embargo, el conflicto ocurre cuando es la unidad médica la que necesita el apoyo y requiere ser evacuada, más aún cuando es indispensable la evacuación de los pacientes de las unidades de terapia intensiva. En la bibliografía mundial poco hay acerca de este tema, por lo general está enfocado a la reconversión de áreas e incremento de la capacidad para atención a saldo masivo de víctimas, pero no sobre cómo evacuar en caso necesario, y donde una decisión errónea puede traer consecuencias fatales. Por esto el Instituto Mexicano del Seguro Social encomendó a un grupo de trabajo, conformado por médicos especialistas del propio Instituto, evaluar y establecer un método para protocolizar la evacuación de estos pacientes con la salvaguarda correspondiente del personal y del paciente sin que los estándares de calidad en la atención se alteren.

Elevated triglycerides/HDL-cholesterol ratio associated with insulin resistance.

BACKGROUND: Cardiovascular disease is the main cause of death worldwide and insulin resistance (IR) plays an important role for its development. In addition, IR has been associated with hypertension and metabolic syndrome according to the triglyceride/HDL-cholesterol (TGL/HDL) ratio. We undertook this study to determine whether the TGL/HDL ratio is associated with IR in apparently healthy subjects. METHODS: A cross-sectional study including healthy men and nonpregnant women was performed. Individuals with IR were compared against subjects without IR. Variables studied were age, gender, body mass index, and waist circumference. Exclusion criteria were chronic diseases such as renal disease, hepatic disease, malignancy, and diabetes. RESULTS: A total of 177 subjects were enrolled, 117 females (66.1%) and 60 males (33.9%). Of these, 145 (93 females and 52 males) with IR were compared against 32 subjects (24 females and 8 males) without IR. Elevated ratio TGL/HDL ratio was detected in 89 (61.4%) and 12 (38.6%) subjects with and without IR, respectively. The elevated TGL/HDL ratio was significantly associated with IR (OR 2.64, 95% CI = 1.12-6.29). CONCLUSIONS: In apparently healthy subjects, elevated TGL/HDL ratio was significantly associated with the presence of IR.

Pathophysiological implications between chronic inflammation and the development of diabetes and obesity.

The different theories about the mechanisms involved in the development of metabolic disease and its complications converge in the presence of an etiologic chronic proinflammatory state. Chronic inflammation is, at present, the central pathophysiological mechanism involved in the genesis of metabolic diseases. The multiple interactions between the immune system, adipose tissue, the vascular wall and the pancreas are the issues addressed in this review, focusing on specific intracellular and molecular aspects that may become new therapeutic targets. These lead to a proinflammatory, prothrombotic state as well as to proapoptotic endothelial damage that allows the development of atherosclerosis and, consequently, cardiovascular disease. The multiple immunopathological processes associated with the etiology and pathophysiology of different chronic diseases is still in the process of being fully elucidated, allowing the development of new therapeutic targets.

[Alveolar hemorrhage secondary to generalized systemic lupus erithematosus treated with recombinant activated factor VII. Case report and literature review]. / Hemorragia alveolar secundaria a lupus eritematoso generalizado, tratada con factor VII recombinante activado. Reporte de un caso y revisión de la literatura.

Alveolar hemorrhage is a severe complication of systemic lupus erithematosus (SLe) associated with high mortality. Treatment includes administration of steroids and cyclophosphamide. Additionally, some reports have recommended the use of plasmapheresis, azathioprine and methotrexate. There is a single case reported in the literature in which recombinant activatedfactor VII (rFVIIa) was used to control severe hemorrhage secondary to alveolitis unresponsive to standard treatment. We report the case of a patient with SLE who developed severe alveolar hemorrhage unresponsive to standard measures, but who was successfully treated with rFVIIa.

Hemorragia alveolar secundaria a lupus eritematoso generalizado, tratada con factor VII recombinante activado: reporte de un caso y revisión de la literatura / Alveolar hemorrhage secondary to generalized systemic lupus erithematosus treated with recombinant activated factor VII: case report and literature review

La hemorragia alveolar es una complicación grave del lupus eritematoso generalizado (LEG), asociada a una elevada mortalidad. El tratamiento de esta complicación se apoya en el uso de corticoesteroides, ciclofosfamida; en algunas series, se recomienda el uso de metrotexate, azatioprina y plasmaféresis. En la literatura se encuentra un solo caso informado en el cual se informa el empleo del factor VII recombinante activado (FVIIra) como opción terapéutica para la hemorragia secundaria a alveolitos, refractaria al tratamiento habitual. Presentamos el caso de una paciente que desarrolló hemorragia alveolar grave con diagnóstico previo de LEG y que se manejó con FVIIra.

Alveolar hemorrhage is a severe complication of systemic lupus erithematosus (SLe) associated with high mortality. Treatment includes administration of steroids and cyclophosphamide. Additionally, some reports have recommended the use of plasmapheresis, azathioprine and methotrexate. There is a single case reported in the literature in which recombinant activatedfactor VII (rFVIIa) was used to control severe hemorrhage secondary to alveolitis unresponsive to standard treatment. We report the case of a patient with SLE who developed severe alveolar hemorrhage unresponsive to standard measures, but who was successfully treated with rFVIIa.

Mucormicosis renal aislada / Isolated renal mucormicosis

La mucormicosis es una infección causada por hongos de la clase Zygomycetes. Existen varias formas de presentación clínica, siendo las más comunes la rinocerebral y la pulmonar. La mucormicosis renal aislada es un tipo de mucormicosis muy poco frecuente hasta el momento; se han reportado 25 casos en la literatura. Se presenta el caso de una paciente con leucemia aguda que desarrolló mucormicosis renal aislada, y se revisa la literatura.

Mucormycosis is an infection caused by a class Zygomycetes fungi. The rhinocerebral and pulmonary are the most common clinical presentations. Renal mucormycosis is a very rare form. To date, only 25 cases have been reported in the literature. We describe the case of a patient with leukemia who developed isolated renal mucormycosis and review the literature.

[Recombinant factor VII activated in non-hemophiliac patients with acute severe hemorrhage in the intensive care unit]. / Factor VII recombinante activado en pacientes no hemofílicos con hemorragia aguda grave en la unidad de terapia intensiva.

BACKGROUND: Severe hemorrhage is a frequent complication with multiple etiologies and high morbi-mortality observed among critically ill patients. Recombinant Factor VIla (rFVlla) constitutes a new therapeutic alternative. OBJECTIVE: Analyze the evolution in a non-hemophiliac patient group with severe hemorrhage treated with rFVlla. MATERIAL AND METHODS: Ten non-hemophiliac patients with severe hemorrhage, five men and five women between 18 and 74 years, were included and treated with rFVIIa. We used a t test for statistic analyses. Significance was set at p < 0.001. RESULTS: Among patients treated with rFVlla, hemorrhage was controlled and the use of blood products was significantly diminished (p < 0.001). Coagulation tests, fibrinogen levels, platelet count and perfusion parameters increased significantly (p < 0.001). CONCLUSIONS: rFVIIa is a therapeutic alternative for the treatment of severe hemorrhage not controlled by conventional management.

[Toxic epidermal necrolysis]. / Necrolisis epidérmica tóxica.

Toxic epidermal necrolysis is the prototype of a proapoptotic disease characterized by system CD95 dysrregulation. Drugs constitute the main antigenic triggers. Hystopatologically it is characterized by epidermis detachment and necrosis with apoptotic keratinocytes. Clinical presentation includes erithematous-ampullous lesions in the skin and mucous membranes. It is associated with serious complications such as severe sepsis and septic shock. The management in the intensive care unit includes support treatment and specific treatment with immunoglobulins that alter disease course. Recombinant activated Factor VII is effective to control the associated microvascular haemorraghe.

Factor VII recombinante activado en pacientes no hemofílicos con hemorragia aguda grave en la unidad de terapia intensiva / Recombinant factor VII activated in non-hemophiliac patients with acute severe hemorrhage in the intensive care unit

Antecedentes. En el enfermo grave, la hemorragia crítica aguda refractaria al manejo convencional es una complicación frecuente de etiología multifactorial con alta morbilidad y mortalidad. El factor VII recombinante activado (FVIIra) es una nueva alternativa terapéutica en estos casos. Objetivo. Presentar el análisis descriptivo en pacientes no hemofílicos con hemorragia grave tratados con FVIIra. Material y métodos. Diez pacientes no hemofílicos con hemorragia grave, cinco hombres y cinco mujeres, edad entre 18 y 74 años, tratados con FVIIra. Se aplicó una prueba de t para el análisis estadístico. Se consideró una p < 0.001 como significativa. Resultados. Después de la administración del FVIIra se controló la hemorragia y disminuyó el uso de hemoderivados en los diez pacientes tratados (p < 0.001). Los tiempos de coagulación, concentraciones de fibrinógeno, cuenta plaquetaria y parámetros de perfusión tisular mejoraron significativamente después de la aplicación del FVIIra (p < 0.001). Conclusiones. El FVIIra es una alternativa terapéutica útil en enfermos graves que cursan con hemorragia crítica aguda no controlada con el manejo convencional.

BACKGROUND: Severe hemorrhage is a frequent complication with multiple etiologies and high morbi-mortality observed among critically ill patients. Recombinant Factor VIla (rFVlla) constitutes a new therapeutic alternative. OBJECTIVE: Analyze the evolution in a non-hemophiliac patient group with severe hemorrhage treated with rFVlla. MATERIAL AND METHODS: Ten non-hemophiliac patients with severe hemorrhage, five men and five women between 18 and 74 years, were included and treated with rFVIIa. We used a t test for statistic analyses. Significance was set at p < 0.001. RESULTS: Among patients treated with rFVlla, hemorrhage was controlled and the use of blood products was significantly diminished (p < 0.001). Coagulation tests, fibrinogen levels, platelet count and perfusion parameters increased significantly (p < 0.001). CONCLUSIONS: rFVIIa is a therapeutic alternative for the treatment of severe hemorrhage not controlled by conventional management.

[Isolated renal mucormicosis]. / Mucormicosis renal aislada.

Mucormycosis is an infection caused by a class Zygomycetes fungi. The rhinocerebral and pulmonary are the most common clinical presentations. Renal mucormycosis is a very rare form. To date, only 25 cases have been reported in the literature. We describe the case of a patient with leukemia who developed isolated renal mucormycosis and review the literature.